Care Bill [HL]

Lord Willis of Knaresborough Excerpts

Tuesday 21st May 2013 Lords Chamber

[Lord Willis of Knaresborough]

My Lords, what a privilege it is to follow the noble Baroness, Lady Bakewell. If there is to be a commissioner for the old in England, I second her nomination at this point.

I also congratulate the Government on bringing together these timely reforms to our social care system. When the noble Baroness, Lady Bakewell, was talking about the problems for local government, I was reminded that it is 20 years since I was elected to North Yorkshire County Council for the first time and put in charge of looking after the budget for adult social services. It was an impossible task 20 years ago. It is an impossible task today. Her remarks are very timely in concentrating our efforts on getting that right.

Parts 1 and 2 begin to address key questions of affordability and access addressed by the Dilnot commission and the issues of quality and safeguarding highlighted by the Francis report. Although modernising the legal framework, as proposed by the Law Commission, and clarifying the rights of individuals and their carers, is an important step, no one should suggest that the Bill will rectify decades of neglect in our social care system. Here, I agree very strongly with my noble and learned friend Lord Mackay that not until we have completely aligned our health and social care systems can many of the issues recognised by Dilnot be fully addressed. Nor would anybody suggest that the proposed new funding arrangements will be a panacea, but they provide at least a more equitable solution than exists at present and afford the nation a breathing space until a more radical solution can be found. I say “more radical” because the reality is that at the current rate of increased demand our health and social care system is not sustainable.

About 30% of the UK population currently suffers from a chronic disease, many with co-morbidities, and the rates of increase are frightening, as are the costs. Seven and a half million of us are being treated for hypertension—many I suspect in this Chamber at the moment—which is up 11% since 2006-07; 2.5 million are treated for diabetes, which is up 25%; 1.8 million have chronic kidney disease, which is up 45% since 2007; 800,000 have long-term cancers, which is up 79% since 2007; and 270,000 have long-term dementia, which is a rise of 25% over that six-year period.

Unless we seek better ways of preventing the onset of chronic conditions and managing them more effectively in the community, or even better finding cures, many of the worthy reforms in this Bill will merely provide respite care. This is why I am so supportive of Part 3, the setting up of Health Education England and the Health Research Authority as arm’s-length bodies. The way we will transform the health and care landscapes radically is by improving the education and training of the workforce, and by giving it the tools to transform patient care by using our outstanding research base.

Health Education England has already made a hugely positive start under the excellent leadership of Sir Keith Pearson, but the need to move swiftly to NDPB status to make sure that we align workforce planning with education and training is essential. What is missing from the legislation is a duty to future proof workforce supply into the NHS and social care system. There should not be a three-year plan for LETBs but a 10-year rolling target so that we avoid the feast and famine often associated with kneejerk reactions from government Ministers as problems of nurse, doctor and consultant shortages appear.

We cannot allow a return to local, short-term self-interest that is the real danger for the LETBs; nor must we exclude the private and voluntary sectors, the key role that they must play in workforce planning, and—crucially—the contribution that they must make to training and education. When he replies I hope the Minister will say how the private and voluntary sectors will be brought in. Incidentally, I am delighted that in Clause 82 there is now a duty for Health Education England to promote research. I congratulate the draft Bill committee for getting that into the Bill, but why does this duty not extend to the LETBs? Improvements will come about only if all the workforce recognises the value of research and puts it at the heart of its daily routines. LETBs are crucial to this agenda. Perhaps the Minister can explain why they have been excluded from that duty.

There are many other issues that need to be raised over Health Education England, but one requires an urgent response. The damning criticism in the Francis report about the role of healthcare workers is largely ignored in this legislation, as are crucial elements concerning nurse education. Francis was clear about the need to train, regulate and register HCAs. These recommendations were also strongly made by the recent commission that I chaired, but in the Bill there is no regulation and no registration, and only a minimalist training programme that is not mandatory.

Can I suggest to the Minister that at the earliest possible date Skills for Health is quietly retired, that new standards are set by the NMC and that Health Education England is mandated to ensure high-quality training with appropriate certification for all healthcare support workers? I understand the challenges of adopting a fully fledged registration scheme, but ensuring that any healthcare support worker who cares directly for patients is trained to a mandatory standard, and that training is certificated and registered for inspection with employers, is surely achievable. Making employers legally responsible for registering the competency of their staff and regularly updating that competency safeguards patients, staff and the reputation of the provider.

Finally, I am delighted with the progress made on the HRA so far. The HRA has demonstrated that it is more than an enhanced national ethics service, which I feared it might become, and I congratulate the Minister and his colleagues on ensuring that it was given that freedom. The crucial next step of creating an NDPB with scope to make the NHS and our social care system the most research-intensive in the world is hugely exciting. However, there remains timidity about the legislation in this Bill. In 2011, the Academy of Medical Sciences highlighted the need for better and more streamlined regulation, and we are not there yet. Clause 93 gives the HRA the duty to promote the co-ordination and standardisation of practice in the UK with regard to health and social care research, but will this extend to the removal of unnecessary levels of regulation?

At a recent Science and Technology Select Committee hearing, part of its inquiry into regenerative medicine, one regulator said to the members, who included the noble Lord, Lord Winston, that because the science was complicated, so must the regulation be. That is what bedevils the regulatory framework for research. The power of different regulators to gold-plate their regulation continues to worry me. Does the HFEA really have a role in embryonic stem cell research, or could its regulatory functions be subsumed by the HRA or indeed be merged with the Human Tissue Authority? Will the HRA have the powers to abolish, or at least to recommend to Parliament the abolition of, unnecessary regulators, or will those regulators, with their independence, still have the upper hand?

As we move to more stratified medicines, regenerative medicine and greater emphasis on genomics and bioinformatics, the key will be to move fast with often small groups or lone patients. The current system of regulation is too burdensome and cumbersome for us to be able to act. The system is simply not fit for purpose. Surely we should be seeking to strengthen the powers of the HRA so that it can decide appropriate regulatory pathways, rather than the existing regulators.

A similar issue arises with National Health Service research and development permissions. The HRA has done brilliantly in streamlining local ethics approvals, but there are still difficulties with individual trusts over site approvals. Not only does each site have to give approval, but if there are variations to a clinical trial, the whole process has to be repeated. This is nonsense if we are aiming for more trials involving more patients at more sites. Simply publishing good guidance, as expected in Clause 98, is insufficient. I hope the Minister will go further and say how the HRA will ensure that trusts have regard to its guidance. Of course, the success of research and the HRA will depend significantly on public buy-in, an issue which the Joint Committee took very seriously. Transparency is key, and the open publication of data should be a statutory requirement for the HRA. The Association of Medical Research Charities, which I chair, has just published Our Vision for Research in the NHS, which includes, from all members of the charity, a call to publish research results and make them accessible.

This is an excellent Bill. It has huge potential. It is not a panacea. It is a great start, but it needs a little bit of courage, and I urge the Minister to have that courage.